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WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…

psychiatryintensive caresystemdelayaripiprazole depot
WAhome2025-12-22

Inquest into the Death of Child LK (Name Subject to Suppression Order)

14y · Male·epilepsy in a boy with Influenza B and COVID-19 infections

Child LK was a 14-year-old Aboriginal boy in state care who died suddenly on 24 August 2023 from an unwitnessed epileptic seizure precipitated by concurrent Influenza B and COVID-19 infections. He had been diagnosed with…

paediatricsemergency medicinecommunicationsodium valproate
WA2025-12-17

Inquest into the Death of Child RK (Name Subject to Suppression Order)

14y · Female·ligature compression of the neck (hanging)

Child RK, aged 14, died by suicide while in Department of Communities care at a therapeutic residential group home on 20 April 2022. She had Complex PTSD from childhood trauma and presented multiple times to emergency de…

paediatricsgeneral practicecommunicationsystemmelatonin
WA2025-12-17

Inquest into the Death of Jamie Frederick GINN

50y · Male·cocaine toxicity

Jamie Frederick Ginn, 50, died from cocaine toxicity on 10 October 2023 while in custody at Perth Watch House (PWH). He had ingested approximately one teaspoon of cocaine hydrochloride; the coroner could not determine wh…

systemcocaine
WAcommunity2025-12-09

Inquest into the Suspected Death of Eric Donald BRANDRICK

47y · Male·unascertained

Eric Donald Brandrick, aged 47, disappeared from his home in North Fremantle, Western Australia, after 31 December 1989. He had suffered a severe stroke in September 1988 causing left-sided paralysis, visual impairment, …

emergency medicinegeneral medicine
WA2025-12-08

Inquest into the Death of Ashley James BROPHO

Male·Neck injury in a man with atherosclerotic heart disease

Ashley James Bropho, a vulnerable remand prisoner with intellectual impairment, schizophrenia, diabetes, previous myocardial infarction with stent, and atherosclerotic heart disease, was killed on 9 March 2023 at Hakea P…

correctional healthsystem
WAhospital2025-12-05

Inquest into the Death of Leslie Charles LINTON

64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis

Leslie Charles Linton, a 64-year-old man with severe triple-vessel coronary artery disease, presented to Royal Perth Hospital on 15 December 2023 with an infected foot wound and acute psychosis. Initial troponin elevatio…

cardiologypsychiatryrisperidone
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
WAhospital2025-11-27

Inquest into the Death of Stephen Joseph SCHIPP

58y · Male·complications of oesophageal cancer, with terminal palliative care

Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…

oncologypalliative caresystemdelaychemotherapy
WAcommunity2025-11-05

Inquest into the Death of Child WK (Name Subject to Suppression Order)

8y · Male·Streptococcus pyogenes and parechovirus infection

An eight-month-old boy in state child protection care died from Streptococcus pyogenes and parechovirus coinfection. He presented to regional ED on 2 September with fever and ear infection signs, then 4 September with mi…

general practiceemergency medicineamoxicillin
WAcommunity2025-10-27

Inquest into the Suspected Death of Stephen ANGEL

Male·unascertained

Stephen Angel, a Western Australian man, disappeared while kayaking off Cape Peron on 3 April 2019. His kayak, paddle, and personal locator beacon were found during an extensive three-day search, but his body was never r…

WAcommunity2025-10-27

Inquest into the Suspected Death of Simon GURRIER-JONES

25y · Male·unascertained

Simon Gurrier-Jones, aged 25, disappeared on 19 June 2003 after an embarrassing interaction with his female housemate. A suicide note was found on his computer, along with search history for methods of suicide. He drove …

WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

Guido Michel, a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 after entering State Forest near Flint, WA with c…

psychiatrygeneral practicesystemcommunicationdextroamphetamine
WAcommunity2025-09-17

Inquest into the Suspected Death of Wayne Michael PARKER

60y · Male·Unknown; likely suicide but natural causes or accident cannot be excluded

Wayne Michael Parker, a 60-year-old man with chronic degenerative spinal disease and chronic pain managed with opioid medications, disappeared on 3 June 2023 from Mount Barker, Western Australia. He drove to Mount Magog …

pain medicinegeneral practiceoxycodone
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…

psychiatrypsychologysystemcommunicationamitriptyline
WAcommunity2025-09-15

Inquest into the Suspected Death of Nicholas Lutci PAVLIDIS

Male·unascertained

Nicholas Pavlidis disappeared in October 2015 after last being seen alive on 14 October 2015. His abandoned vehicle was reported to police on 24 October 2015 in Yanchep bushland, but initial police response treated it as…

general practicepsychologysystemdelayfluoxetine
WAcommunity2025-08-22

Inquest into the Death of David Kalunda FLYNN

2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity

David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…

general practicegeneral surgerymedicationproceduralmorphine
WAcommunity2025-08-11

Inquest into the Suspected Death of Simon Brian HARRINGTON

34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…

Simon Harrington, a 34-year-old man with depression and psychotic features, disappeared on 10 January 2011 after starting a new job that triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle…

psychiatryemergency medicinecommunicationquetiapine
WAhome2025-07-23

Inquest into the Death of Lynn Marie CANNON

51y · Female·Multiple sharp force injuries to the chest

Lynn Marie Cannon, 51, was murdered by her estranged husband Paul Cannon on 5 December 2022 at his residence. After ending their 25-year marriage characterised by coercive control, she had begun a new relationship. When …

WAhospital2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent behavior, died on 9 November 2022 at Joondalup Health Campu…

psychiatryintensive caresystemdelayclozapine

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